Module 1 - Overview of Medicare Program Basics: Choices, Eligibility, and Benefits - MEDIGAP COVERAGE Flashcards
Medigap (Medicare Supplemental Insurance):
Medigap insurance:
Works only with Original Medicare.
Is sold by private insurance companies to fill “gaps” in Original Medicare coverage, such as all or part of the deductibles or coinsurance amounts.
It coordinates with original Medicare coverage.
Some Medigap policies cover limited benefits not covered by Part A or Part B of Original Medicare, Such as extra days of coverage for inpatient hospital care or foreign travel emergency care. Generally, Medigap doesn’t cover long-term care (like care in a nursing home), vision or dental services, hearing aids, eyeglasses, or private-duty nursing.
Generally, does Medigap NOT cover?
Generally, Medigap doesn’t cover long-term care (like care in a nursing home), vision or dental services, hearing aids, eyeglasses, or private-duty nursing.
What Medigap is NOT:
-Medigap is NOT a Medicare Advantage (Part C) plan or other Medicare health plan.
- Medigap is NOT Original Medicare. Medigap supplements Original Medicare benefits only.
-In addition,
--A Medigap plan cannot be used with a Medicare Advantage health plan. -- It is illegal to sell a Medigap plan to someone who is already in a Medicare Advantage health plan.
Type of Medigap Policies:
Medigap policies are available in standardized benefit plans, identified by certain letters between A and N
(however, different plans are offered in Massachusetts, Minnesota, and Wisconsin).
When can a beneficiary sign up for a Medigap plan?
Turning age 65 and signing up for Part B triggers a six-month Medigap open enrollment period when Medigap insurers must issue you a policy, regardless of any pre-existing conditions. This is called a guaranteed issue right.
In certain limited instances, can leaving a Medicare Advantage plan trigger a guaranteed issue right?
Yes. In certain limited instances, leaving a Medicare Advantage plan may trigger a guaranteed issue right. Some states have additional guaranteed issue periods for Medicare beneficiaries. Agents should look into state-specific Medigap laws.
What do Medigap plans pay for:
All Medigap plans pay for some or all of the following costs:
- Part A coinsurance
- Coverage for 365 additional hospital days when Medicare coverage for hospitalization ends
- Part B coinsurance or copayment
- Blood (First 3 Pints)
- Hospice care coinsurance or copayment
Does Medigap pay for Part A Coinsurance?
Yes, Medigap pays for some or all of Part A coinsurance.
Does Medigap pay for coverage for 365 additional hospital days?
Yes, Medigap pays for some or all of 365 additional hospital days when Medicare coverage for hospitalization ends
Does Medigap pay for Part B coinsurance or copayment?
Yes. Medigap pays for some or all of Part B coinsurance or copayment.
Does Medigap pay for the first 3 pints of blood?
Yes. Medigap pays for some or all of the cost for the first 3 pints of blood.
Does Medigap pay for hospice care coinsurance or copayment?
Yes. Medigap pays for some or all of hospice care coinsurance or copayment.
Beneficiaries with Medigap Plans with/without Drug Coverage:
- Medigap plans H, I, and J offer non-Medicare drug coverage. These plans could no longer be sold as of January 1, 2006. However, some beneficiaries may have decided to keep their H, I, or J policy with the drug coverage they had before January 1, 2006
- Individuals who are enrolled in Medigap plans may only obtain Medicare drug coverage (Part D) through a stand-alone prescription drug plan.
- To enroll in Part D, individuals who have Medigap plans H, I, or J may:
– keep their Medigap coverage with the drug portion of the coverage removed and enroll in a Part D PDP plan; or
– drop their Medigap coverage and enroll in an MA-PD or other health plans with a PDP.
Beneficiaries with Medigap Plans with/without Drug Coverage -
Medigap plans H,I, and J offer non-Medicare drug coverage:
Medigap plans H, I, and J offer non-Medicare drug coverage. These plans could no longer be sold as of January 1, 2006. However, some beneficiaries may have decided to keep their H, I, or J policy with the drug coverage they had before January 1, 2006
What drug coverage may individuals who are enrolled in Medigap obtain?
Individuals who are enrolled in Medigap plans may only obtain Medicare drug coverage (Part D) through a stand-alone prescription drug plan.
How may individuals who have Medigap plans H, I or J enroll in Part D?
To enroll in Part D, individuals who have Medigap plans H, I or J may do either one of the following:
- keep their Medigap coverage with the drug portion of the coverage removed, and enroll in a Part D PDP plan; or
- Drop their Medigap coverage and enroll in an MA-PD or other health plans with a PDP.
Beneficiaries with Medigap Drug Coverage - Creditable Coverage:
–Non-Medicare insurers (including Medigap plans) are required to notify beneficiaries annually whether or not the prescription drug coverage they have is creditable (coverage that expects to pay, on average, at least as much as Medicare’s standard Part D coverage expects to pay).
– All beneficiaries who do not maintain creditable coverage must pay a Part D late enrollment penalty if they wish to enroll in Part D unless they qualify for “Extra Help” or enroll in Part D during the special enrollment period for loss of creditable coverage.
– Beneficiaries who previously had creditable coverage and are informed that their non-Medicare drug coverage is no longer creditable will have a special enrollment period to enroll in a Part D plan without the obligation to pay a Part D late enrollment penalty.
Beneficiaries with Medigap Drug Coverage - Creditable Coverage:
Are Non-Medicare insurers (including Medigap plans) required to notify beneficiaries whether their prescription drug coverage is or is not creditable?
Yes. Non-Medicare insurers (including Medigap plans) are required to notify beneficiaries annually whether or not the prescription drug coverage they have is creditable.
Regarding Part D, what is “Creditable Coverage”?
Creditable coverage is coverage that expects to pay, on average, at least as much as Medicare’s standard Part D coverage expects to pay.
If a beneficiary desires to enroll in Part D, will s/he suffer a penalty for failing to maintain creditable coverage?
All beneficiaries who do not maintain creditable coverage must pay a Part D late enrollment penalty if they wish to enroll in Part D unless they qualify for “Extra Help” or enroll in Part D during the special enrollment period for loss of creditable coverage.
What happens to a beneficiary who previously had creditable coverage is informed that their non-Medicare drug coverage is no longer creditable?
Beneficiaries who previously had creditable coverage and are informed that their non-Medicare drug coverage is no longer creditable will have a special enrollment period to enroll in a Part D plan without the obligation to pay a Part D late enrollment penalty.
In relationship to Part D, what is the “Extra Help” program?
The “Extra Help” program is a Medicare initiative designed to assist individuals with limited income and resources in paying for Medicare drug coverage, also known as Part D. The program helps cover costs such as premiums, deductibles, coinsurance, and other expenses associated with Part D.
Here are some key points about the “Extra Help” program:
You won’t have to pay a Part D late enrollment penalty while you get Extra Help.
Some people qualify for Extra Help automatically, while others have to apply.
The program isn’t available in Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, or American Samoa. However, other programs are available in those areas to help people with limited income and resources.
If you qualify for Extra Help, you’ll be automatically enrolled in a Medicare drug plan (Part D), if you don’t have one already.
You can apply for Extra Help at any time before or after you enroll in Part D.
Please note that the level of help you receive depends on your income and assets. If you’re interested in applying for the “Extra Help” program, you can do so through the Social Security Administration.
Medigap rules for individuals who become eligible for Medicare after December 31, 2019
–Individuals who attained age 65 on or after January 1, 2020, or first become eligible for Medicare due to age, disability, or end-stage renal disease on or after January 1, 2020, may not purchase a Medigap plan that pays the Part B deductible (generally plans C, F or high deductible F, but the prohibition also applies in waiver states with non-standard packages).
– Individuals previously enrolled in plans that cover the Part B deductible may remain enrolled in those plans.
– Individuals who became eligible for Medicare before 2020 may enroll in plans that cover the Part B deductible.
What are the Medigap plans available to all beneficiaries??
The Medigap plans are:
A, B, D, G, K, L, M, N, C, and F
All of these plans pay 10% of Original Medicare’s Part A Coinsurance and Hospital Benefits
